Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victorian Post Acute during CMS and state inspections, most recent first.
A resident with hypertension and severe cognitive impairment was administered blood pressure medications despite vital signs being outside ordered parameters. The MAR showed multiple instances where carvedilol and clonidine were given when the resident's blood pressure or heart rate was below the specified thresholds. Interviews with LVNs and facility leadership confirmed the failure to follow physician orders, highlighting a significant medication error.
The facility failed to ensure staff wore appropriate PPE for residents under transmission-based precautions. A resident with COVID-19 did not receive care with the required face shield, and another resident with an indwelling medical device did not receive care with the necessary gown and gloves during high-contact activities. Interviews confirmed the oversight in PPE usage, highlighting a deficiency in infection control measures.
A resident with Multiple Sclerosis and a history of leg fractures experienced ongoing right knee pain and swelling after a fall. The facility failed to notify the physician for three days, resulting in delayed care. The resident was eventually sent to the emergency department for evaluation and returned with a right leg immobilizer.
A resident complained of rectal pain, but the facility failed to document a pain assessment or administer the prescribed PRN Acetaminophen. The DON confirmed the oversight, which violated the facility's pain management policy.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of blood pressure medications. Resident #10, who had a medical history of essential primary hypertension and severe cognitive impairment, was administered carvedilol and clonidine despite their vital signs being outside the ordered parameters. The orders specified that carvedilol should be held if the resident's systolic blood pressure was less than 100 mmHg or heart rate was less than 55 bpm, and clonidine should be held if the systolic blood pressure was less than 110 mmHg. However, the Medication Administration Record (MAR) showed that these medications were administered multiple times when the resident's vital signs were below the specified thresholds. Interviews with nursing staff and facility leadership confirmed the failure to adhere to the physician's orders. Licensed Vocational Nurses (LVNs) acknowledged administering the medications despite the resident's vital signs being outside the ordered parameters. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both stated that nurses should follow physician orders and not administer medications if the vital signs are outside the specified parameters. The facility's Administrator also emphasized the expectation for nurses to adhere to the ordered parameters to prevent adverse effects on residents.
Failure to Adhere to PPE Protocols for Residents on Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) when providing care to residents under transmission-based precautions. In the case of Resident #30, who was admitted with a diagnosis of COVID-19, staff were required to use contact and droplet isolation precautions. However, during an observation, a Licensed Vocational Nurse (LVN) entered the resident's room wearing a gown, gloves, and an N-95 mask but failed to wear a face shield, which was required for eye protection. Interviews with the LVN, Infection Preventionist (IP), Director of Nursing (DON), and Administrator confirmed that a face shield was necessary when entering the room of a COVID-19 positive resident. In another instance, Resident #19, who had end-stage renal disease and an arteriovenous shunt for dialysis, required enhanced barrier precautions (EBP) during high-contact care activities due to the presence of an indwelling medical device. Despite signage on the resident's door indicating the need for gown and gloves during such activities, a Certified Nursing Assistant (CNA) entered the room wearing only an N95 mask and provided care without donning the required gown and gloves. The CNA acknowledged the oversight after observing the signage and stated that she should have worn the appropriate PPE. Interviews with the IP and DON reiterated the necessity of wearing gloves and a gown when performing high-contact activities for residents on EBP. The facility's failure to adhere to these PPE protocols for both residents highlights a deficiency in the implementation of infection prevention and control measures, as outlined in the facility's policies and CDC guidance.
Failure to Notify Physician of Resident's Ongoing Pain and Swelling
Penalty
Summary
The facility failed to notify the physician when a resident continued to experience right knee swelling and pain after a fall. The resident, who had a history of Multiple Sclerosis and leg fractures due to falls, was assisted to the ground by a nurse during a transfer from the toilet to a shower chair. Initially, no visible injuries were noted, and pain management was provided. However, the resident continued to complain of pain and swelling in the right knee over the next two days, but the physician was not notified until the third day. This delay in notification resulted in a delay of care for the resident. Upon eventual notification, the physician noted the ongoing and worsening pain and swelling in the resident's right knee and decided to send the resident to the emergency department for urgent evaluation. The facility's policy required nurses to notify the physician of any changes in a resident's condition, including pain and swelling, but this protocol was not followed. The physician confirmed that no calls or notifications were received from the nursing staff on the days the resident's condition worsened. An x-ray revealed no new fractures or soft tissue injury, and the resident returned to the facility with a right leg immobilizer.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to ensure appropriate pain management and assessment for a resident who complained of pain. On 12/28/23, the resident reported pain in the rectum area, but there was no documented evidence of a pain rating scale assessment or administration of the prescribed PRN pain medication, Acetaminophen 325 mg. The Medication Administration Record (MAR) for December 2023 confirmed that the pain medication was not given. During an interview and record review on 3/7/24, the Director of Nursing (DON) confirmed the absence of both the pain assessment and the administration of pain medication. The facility's policy on Pain Assessment and Management, revised in October 2022, mandates that acute pain should be assessed every 30 to 60 minutes until relief is obtained, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoias San Francisco Convalescent Hospital | 0.2 mi | ★★★★★ | 13 | 0 |
| Central Gardens Post Acute | 0.4 mi | ★★★★★ | 0 | 0 |
| Laurel Heights Community Care | 0.5 mi | ★★★★★ | 0 | 0 |
| San Francisco Towers | 0.6 mi | ★★★★★ | 12 | 0 |
| Pacific Heights Transitional Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.